The sixth annual report to the Board on the Global Fund Secretariat’s work to promote community-, rights- and gender- (CRG-) based responses to HIV, TB and malaria has been caught between two chairs: the long-running attempt to keep CRG-based as well as community and civil-society engagements at the center of Global Fund grants’ programming, with the tsunami of the COVID-19 pandemic that has affected every aspect of the Global Fund’s work and every aspect of communities’ responses.
This report, which was presented to the Global Fund’s Board in advance of the 43rd Board meeting held on 14-15 May, does not – and could not – fully address the adjustments that would have been necessary to accommodate more coronavirus-related measures, because it was submitted for review to the Strategy Committee’s 12th meeting in March 2020. This was around the time that the impacts of COVID-19 were starting to become clear, and just after the Global Fund’s first COVID-19-inflected change to policy. (This initially allowed for some reprogramming of savings/underspent funds in existing grants.) It was also before the Global Fund partnership took the full scope of Global Fund coronavirus-related impacts into consideration.
The head of the Secretariat’s CRG Department, Kate Thomson, told the GFO that a huge volume of work on the CRG-related aspects of COVID-19 has been undertaken in the weeks since the report was finalized. (See ‘Further resources’ below.) “What COVID has highlighted is that actions to address human rights and gender barriers, as well as robust and extensive community engagement and responses, are needed now more than ever – not only for the world to successfully tackle COVID-19, but for health responses across the board,” Thomson said.
She added that the CRG team and the Secretariat have focused their efforts on a number of areas such as producing human rights and COVID-19-related guidance; integrating CRG considerations into broader COVID-19 guidance across the three diseases and resilient and sustainable systems for health (RSSH); monitoring communities’ COVID-19-related human rights and access challenges, and a Secretariat-wide plan to protect community and civil-society engagement in Global Fund-related processes within the context of COVID-19.
Achievements and challenges
The majority of the report reviews what the Global Fund has done during the 2017-2019 allocation period to promote CRG-based programming, approaches and policies. It acknowledges that the Global Fund has helped bring comprehensive programming to national scale to reduce human-rights-related barriers; scaled up access to HIV-prevention services for adolescent girls and young women (AGYW), expanded global coverage of services for key and vulnerable populations across the three diseases; and demonstrated its leadership as the largest funder of harm reduction globally.
However, the report points out remaining major challenges, such as the need for further improvement in the quality of human rights and gender analyses included in the HIV proposals, and ongoing limitations in scope and scale of Global Fund-supported services for key vulnerable populations across the portfolio (despite some increases). The report highlights seven areas for enhanced focus and coordination of efforts: (1) Greater and more strategic use of data to inform the focus of investments; (2) Sustain progress in addressing human rights-related barriers and apply lessons learned from the Breaking Down Barriers (BDB) initiative across the portfolio; (3) Accelerate efforts relating to AGYW; (4) Work with partners to promote continued scale-up of programming for key and vulnerable populations; (5) Advance programming that is community-based and community-led; (6) Build on the CRG Accelerate initiative; and (7) Continue to promote meaningful community- and civil-society engagement in all Global Fund-related processes.
The report seeks to address three questions overall, regarding progress made to strengthen the Global Fund’s CRG-related investments, lessons learned in 2017 to 2019, and the Secretariat’s preparations for the 2020-2022 funding cycle. These are carried through each of the report’s sections selectively summarized below, as are descriptions of ‘longer-term challenges and opportunities’ and ‘Spotlight’ case studies.
Strengthening capacity across the Secretariat and broader community engagement
The report states that the priority and responsibility to place communities, and key and vulnerable populations at the center of a rights-based, gender-responsive and equitable global response to AIDS, TB and malaria “lies with the full Secretariat”. Among the elements promoted by the Secretariat in pursuit of this are the CRG Accelerate initiative, the establishment of the BDB Steering Committee, and broader initiatives including the Youth Council and the Country Coordinating Mechanism (CCM) Evolution pilot. (The BDB initiative is a five-year, 20-country initiative set up in 2017 to reduce human rights-related barriers to services.)
CRG Accelerate was a six-month review process in which the Secretariat examined how it could achieve greater impact through better deployment of its resources related to CRG issues. One result was that CRG advisors provide cross-cutting support to designated regions, by working within the Grant Management Division. Another key component of this support was to reinforce (through workshops) country teams’ capabilities to apply a CRG lens to all their grant-management work.
Community systems and responses
This section of the report focuses on the Global Fund’s Strategic Objective 2 (SO2), Building Resilient and Sustainable Systems for Health (RSSH), and highlights the Technical Evaluation Reference Group (TERG) 2019 Review’s observation of “a continued conflation between community-led and community-based responses across the Global Fund partnership”. According to the report, this meant a dominant focus on the extension of service delivery through Community Health Workers (CHWs), “rather than on community-led interventions”. Among other recommendations, the TERG recommended that the Global Fund improve its articulation of “the range of permissible community systems and response interventions” in order to distinguish more clearly between responses that are conducted at community level and responses that are “truly community-led”.
In addition, the Technical Review Panel (TRP) recommended, in its observations on the 2017-2019 funding cycle, that community engagement in response to the three diseases be expanded, especially for issues relating to human rights, gender, and marginalized populations.
In the 2017-2019 allocation period, the CRG Strategic Initiative (CRG-SI) supported a range of activities that have addressed these issues, in the form of short-term technical assistance, longer-term capacity building, and the establishment of six regional platforms to identify and address various barriers faced by communities, specifically regarding access to information that would enable more meaningful engagement in Global Fund processes. (Table 1 on page 8 of the report outlines the key outcomes and achievements in each of these areas.) An external evaluation of the CRG-SI was due to have been completed in April but has been delayed due to COVID-19; it is now expected at the end of May 2020.
Following the TERG and TRP’s recommendations, the Secretariat has made adjustments to the Modular Framework Handbook, by including clear language to promote community-led responses. Constituencies in turn emphasized the importance of community-led monitoring and encouraging its inclusion in government-led plans. According to the report, in 2020, the CRG Initiative will focus on supporting community and civil-society participation in country dialogues throughout the grantmaking process and during countries’ requests for funding for the 2020-2022 allocations.
In addition, the Secretariat has created the CBM (community-based monitoring) Change initiative to promote the uptake and scale-up of mechanisms that enable local communities to gather, analyze and act upon information to improve a range of implementing activities, including budget monitoring, prevention of drug stockouts and ensuring providers’ and decision-makers’ accountability. A ‘Spotlight’ features implementing CBM of HIV treatment in 11 West African countries, where the Global Fund has funded ‘Community Treatment Observatories’ that collect quantitative and qualitative data on access to HIV treatment for key and vulnerable populations. The example highlights the West African Treatment Observatory’s findings on the frequency of stockouts for HIV test kits, ARVs and viral-load testing supplies. Constituencies’ input at the Board meeting included requests for information on how many country grants have included CBM in their funding applications, and on what will be done to ensure that countries prioritize CBM.
Key and vulnerable populations
The Global Fund’s Key Performance Indicator (KPI) 5, under Strategic Objective 1 (SO1), to maximize impact against HIV, TB and malaria, measures service coverage among key populations. This section highlights the need to strengthen countries’ data systems in order to establish better population-size estimates for key populations (only 40% of countries – 24 out of 60 – have data systems in place to report on HIV-related service coverage for at least two key populations, falling short of the 75% target). The report states that strong leadership by national programs is essential to strengthen data systems in the context of key populations. In late 2019, the Secretariat and several partners discussed the possibility of reporting actual service coverage for key populations from 2021. A plan for this will be outlined, in consultation with technical partners, for the Strategy Committee and the Board later in 2020.
The Global Fund has enlisted a range of bilateral partners to support key and vulnerable populations, such as the USAID-funded FHI/LINKAGES initiative, which delivers technical assistance on strategic information and programming for key populations in the US President's Emergency Plan For AIDS Relief- (PEPFAR-) supported countries. (Lesotho is the featured example in this section’s ‘Spotlight’.)
This section also addresses issues related to Challenging Operating Environments and the needs of refugees and internally displaced populations. This includes multi-country approaches and grants; $50 million in multi-country grants has been provided to support key populations. For the 2020-2022 funding cycle, the Global Fund has set aside $890 million for catalytic investments, which will include ongoing support for multi-country approaches supporting key populations, and scaling up community-led and community-based HIV programming for them. Revised guidance from the Secretariat for applications calls for HIV-prevention programming for key populations to be included as a priority intervention in all epidemic settings, in line with the TRP’s recommendation to improve priority setting. The report also notes that the Secretariat has updated its guidance note on Sustainability, Transition and Co-financing to highlight human-rights- and gender-related barriers as a core ‘sustainability’ consideration in national planning.
The Global Fund’s approach to addressing human-rights issues focuses on reducing human-rights-related barriers to health services. Within the monitoring framework for Strategic Objective 3 (SO3), KPI 9 tracks the number of countries that have comprehensive programs aimed at reducing human-rights barriers to services, in the 20 countries that are participating in BDB initiative. The report says that in the last funding cycle, the Global Fund and partners intensified their support to those 20 countries, with $45 million in matching funds made available and technical assistance provided through the CRG Strategic Initiative.
The recent advisory review from the OIG on human rights further informs the lessons learned from BDB as well as many recommendations that the CRG report says will be implemented. Overall, the OIG advisory said that the Global Fund has invested $123 million in the 2017-2019 funding cycle to remove human-rights-related barriers. However, by January 2019, out of 120 countries, 49 had received funding to remove human-rights barriers for HIV, 15 out of 114 countries for TB, and just four out of 72 for malaria.
Advancing gender equality and reaching adolescent girls and young women
The report points out improvements in addressing gender inequities in the 2017-2019 funding cycle, especially with regard to the inclusion of sex- and age-disaggregated data in funding proposals and performance frameworks. However, it also says significant improvements are needed to address gender-related risks and barriers to services within Global Fund investments. The TRP has noted some progress on sex-disaggregated data in the 2017-2019 cycle, but said countries need a broader range of data to strengthen gender analysis in their proposals to the Global Fund, especially for TB and malaria.
The CRG report says the Global Fund has invested more than $200 million for AGYW programming in 13 countries in sub-Saharan Africa in the 2017-2019 funding cycle. The Global Fund’s SO3 commits the Fund to scaling up AGYW programming, with KPI 8 aiming for a 58% reduction in HIV incidence in young women (aged 15 to 24) in those countries. By 2018, overall HIV incidence had declined by 20% from the 2015 baseline in all 13 countries, though seven countries, including the three with the biggest gaps in reaching their targets, are off track. The work of integrating AGYW programming into national strategies and frameworks continues.
In the meantime, the TRP has noted gaps in other areas of programming related to the three diseases that are especially critical for women. These include cervical cancer screening, adolescent-friendly prevention, addressing norms of masculinity that underpin boys’ and men’s risky sexual behavior, and the exclusion of adolescents from gender-based violence interventions. To support the 2020-2022 cycle, the Secretariat has produced a Technical Brief on Gender Equity to inform a general approach to gender equity across all three diseases.
At the Board meeting, some constituencies raised the issue that due to COVID-19, access to sexual and reproductive health services (SRHS) is becoming more difficult, and emphasized the need for governments to classify family planning services as ‘essential services’.
In addition, several constituencies strongly urged greater investment in and attention focused on more strategic use of data to inform the focus of CRG-related investments. One comment called for the improvement and increase in the range of disaggregated data, emphasizing the components of TB and malaria. Other comments specified the need for comprehensive quantitative data – including disaggregated data by age and gender, as well as the promotion of community-driven data – so that inequities across the HIV, TB and malaria responses could be identified. They called for the Secretariat to inform the Board about further progress in these areas during the 2020-2022 allocation cycle.
A separate Secretariat management response to the Office of the Inspector General’s Advisory Review, ‘Removing human-rights-related barriers: Operationalizing the human rights aspects of Global Fund Strategic Objective 3’ (GF-OIG-19-023) was shared with the Board ahead of its 43rd meeting.
- Board Document GF/B43/04 (Report on Community, Rights and Gender) should be available shortly at https://www.theglobalfund.org/en/board/meetings/43/
- The Global Fund's 2017-22 Strategic Key Performance Indicator Framework
- Article from GFO 369 on the OIG Advisory Review on Human Rights
- The Community, Rights and Gender landing page on the Global Fund website
Editor’s note: This article is dated 15 May, which is when this article was uploaded into our automated system. The article was not published until 16 May, the day following the Board meeting. This respects our agreement with the Global Fund concerning when we publish articles that are based on the content of the Board papers.